A couple of weeks ago, after I posted about a very serious emerging bacterial threat, KPC, I received an email from a reader with an elderly relative in the hospital with a very serious case of pneumonia caused by KPC. What he* told me is shocking.

The relative, who has had repeated hospital stays and a previous MRSA infection, was in the hospital for a week before any laboratory cultures were performed. That’s right, a patient with practically every major risk factor for a multidrug resistant infection wasn’t tested for a week. So this patient wasn’t isolated, exposing other ICU patients and staff** for seven days. If there were ever a poster child for immediate laboratory tests and pre-emptive isolation, this patient would be it. Millions of your tax dollars have been spent trying to figure who is most likely to enter a hospital with a multidrug infection. How’s about someone fucking listen?
It gets worse: the primary physician has essentially decided this patient is a lost cause, so instead of administering colistin and tigecycline combination therapy, which usually works, the doctor treating with amoxicillin/sulbactam even though that most likely will not work. This is foolish for two reasons. First, the patient, even while dying, is still a carrier. Treatment will prevent the spread to the staff and visitors. Second, all of the non-target bacteria–many of which can cause disease–will be exposed to amoxicillin/sulbactam, selecting for bacteria resistant to those drugs (and most likely to other drugs of clinical importance).
At some point, people are going to become really pissed off and start suing over antibiotic misuse. And they’ll win. If hospital administrators, doctors, and nurses don’t deal with this voluntarily, the courts will force them to do so. There’s one thing I’m certain of: judges will be awful at practicing medicine and developing public health strategies.*I’m keeping the case anonymous, so don’t read anything into the gender of the letter writer or the patient. Don’t blame the blogga, blame the patriarchy.**The staff aren’t at risk for illness; however, they can act as carriers. KPC isn’t some mystical substance in the ether, it is a biological agent that has to be transmitted.

5 Responses to KPC, Antibiotic Misuse, and the Coming Lawsuits

Terrible and frightening. And as an infectious disease pharmacist, I have trouble understanding the rationale for the antibiotic choices, let alone absense of infection control precautions. But I would also highlight a potential problem that complicates things further, and that is that KPCs are not always identified in the laboratory. The use of automated susceptibility tests (generally fast and reliable, but not 100% accurate) severely limits our micro lab’s ability to identify unusual resistant organsisms, like KPC or ampC in Gram negatives, or heteroVISA. If they’re not specifically looking for it up front in the lab, there’s no guarantee the clinicians will even know about it until it’s too late for the patient. I’d be interested in your suggestions for improving prospective screening.

Susan,
you’re absolutely right: most automated systems are awful at detecting KPCs (Sensititre is the worst). Unfortunately, the best ways to detect KPCs are through disk diffusion methods (Ken Thompson at Creighton has developed them), so you would need staff who know how to do that.
In terms of prospective screening, it’s hard, but here are some thoughts:
1) hVISA: typically, these result from prolonged use of vancomycin, so these patients, if they’re not responding to treatment, should be screened.
2) KPC: this is really rare outside of NYC. If you have a patient who has a history of antibiotic treatment, and has K. pneumoniae, it’s worth doing the appropriate disk diffusion test.
3) ampC: it’s difficult to know what to do because in some facilities it’s difficult to know what to do (i.e., do you test everything?). Most of the larger facilities in MA do (E test: cefepime +/- clauvanate or cefoxitin and cefotetam +/- boronic acid).
As you noted, you have to be looking for these things to find them. If you have the resources (and stored isolates), a prospective survey (for AmpC) might be useful to determine prevalence. Relying solely on automated systems (and some have real problems) is very difficult.

As you noted, you have to be looking for these things to find them. If you have the resources (and stored isolates), a prospective survey (for AmpC) might be useful to determine prevalence. Relying solely on automated systems (and some have real problems) is very difficult

As you noted, you have to be looking for these things to find them. If you have the resources (and stored isolates), a prospective survey (for AmpC) might be useful to determine prevalence. Relying solely on automated systems (and some have real problems) is very difficult